Service Line: Rapid Response Service

Version: 1.0

Publication Date: March 15, 2017

Report Length: 20 Pages

CADTH RAPID RESPONSE REPORT: SUMMARY WITH CRITICAL APPRAISAL

Ureteral Stents: A Review of

Clinical Effectiveness and

Guidelines

SUMMARY WITH CRITICAL APPRAISAL Ureteral Stents: A Review of Clinical Effectiveness and Guidelines 2

Authors: Emily Reynen, Lory Picheca

Cite As: Ureteral stents: a review of clinical effectiveness and guidelines. Ottawa: CADTH; 2017 Mar. (CADTH rapid response report: summary with critical

appraisal).

Acknowledgments:

ISSN: 1922-8147 (online)

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SUMMARY WITH CRITICAL APPRAISAL Ureteral Stents: A Review of Clinical Effectiveness and Guidelines 3

Context and Policy Issues The ureters are muscular tubules that connect the kidneys to the urinary bladder and

allow the passage of urine into the lower urinary tract. Ureteral stents are devices that

are inserted into the ureter to maintain or reestablish patency and facilitate flow of

urine or debris into the bladder.1 Common indications for ureteral stents are to relieve

or prevent intraluminal obstruction caused by calculi, stenosis and genitourinary

malignancies or extraluminal obstruction caused by compression of the ureter by

malignancy or fibrosis.1-4

Ureteral stents are most commonly made from silicone

based material, but are also available in other materials such as polyurethane,

polyethylene and metal.1 Stent material may also be coated to improve tolerability, be

embedded with medication, or be dissolvable. Presently, there is no clear evidence

supporting the optimal choice of stent technology.

Ureteral stents are available in a range of sizes and diameters that can be selected

based on individual patient anatomy. Most ureteral stent have curled pigtail

structures on either end. One pigtail sits in the renal pelvis and the other in the urinary

bladder. The goal of the curled pigtail ends is to reduce stent migration.1 Most often

stents are placed by a urologist in the operating room under cystoscopic guidance.1

Stents may come with extraction strings attached. In patients who require short-term

stent placement, some urologists may leave the extraction strings in place and secure

them to the patients external anatomy. Extraction strings may also be removed by the

urologist at the time of stent placement. Extraction strings can facilitate stent removal

by either the patient or urologist.

Ureteral stents are associated with potential risks and adverse events. Patients have

reported irritative symptoms such as urgency and frequency while stent is in situ.1,2

Patients may experience pain both during stent placement and while the stent is in

place. Common complications of ureteral stents include hematuria, urinary tract

infections (UTI), stent migration and stent encrustation.1,2

The risk of stent

encrustation increases the longer the stent remains in the ureter.1 Stent retention is a

rare but serious complication associated with failure to remove the stent in the

indicated timeframe.1

Canadian, American and European urological organizations have all recently

published guidelines on the management of ureteral stones and the role of short-term

ureteral stents.5-8

Both shockwave lithotripsy (SWL) and ureteroscopy are common

methods for management of ureteral stones.9 The Canadian, American, and

European guidelines all recommend against placement of ureteral stents after SWL

as evidence indicates that stents do not improve stone free rates and may prevent the

passage of debris.5,6,8

Canadian guidelines recommend that ureteral stents be placed

prior to SWL in select patients such as those who have evidence of obstruction, acute

kidney injury (AKI), intractable pain, sepsis, or a solitary kidney.5 The evidence for

stent placement before or after ureteroscopy is more controversial. The European and

American guidelines recommend against routine stent placement prior to

ureteroscopy6,8

but acknowledge that there may be an indication for ureteral stenting

after ureteroscopy in certain clinical situations.6,8

The guidelines also acknowledge

that the optimal duration of ureteral stents in the setting of stones is unknown, but

short-term stent placement (less than 14 days duration) is associated with fewer

adverse events.5,8

SUMMARY WITH CRITICAL APPRAISAL Ureteral Stents: A Review of Clinical Effectiveness and Guidelines 4

This report focuses on evidence for the clinical effectiveness of short-term ureteral

stenting in patients undergoing stone removal or kidney transplant, long-term ureteral

stenting in patients with retroperitoneal carcinoma or obstructed uropathy, and

evidence-based guidelines for long-term use of ureteral stents.

Research Questions 1. What is the clinical effectiveness of short-term ureteral stenting in patients

undergoing stone removal or kidney transplant?

2. What is the clinical effectiveness of long-term ureteral stenting in patients with

retroperitoneal carcinoma or obstructed uropathy?

3. What are the evidence-based guidelines regarding the appropriate patient

indications for the use of ureteral stents long-term?

Key Findings In patients undergoing stone removal, short-term ureteral stenting was found to be

associated with an increase in irritative symptoms, dy